Eyeworld

I MANAGING IRREGUR CORNEAS PRIOR TO CATARACT SURGERY N FOCUS 38 | EYEWORLD | NOVEMBER 2019 Contact information Goerlitz-Jessen: mark.goerlitz.jessen@duke.edu Hirst: lawrie@tapc.net.au Kim: terry.kim@duke.edu Lee: wblee@mac.com Mian: smian@med.umich.edu Rapuano: cjrapuano@willseye.org ever, unnecessary in most cases of EBMD as man- agement involves inducing some fibrosis to increase adherence of the epithelium and underlying basement membrane. A diamond burr is helpful in this case. "I do find that a diamond burr helps reduce the risk of recurrence in my experience," Dr. Mian said. "With the slight addition of roughening with the diamond burr, they get less erosions." But not everyone uses it. "Generally, we do not use a diamond burr for treating EBMD," wrote Dr. Kim and Dr. Goerlitz-Jessen. "To remove epithelium for both SK and PTK we use dilute alcohol to loosen the tissue and then remove it with a combination of Weck-Cel sponges (BVI) and a Maloney spatula." Meanwhile, MMC is best avoided in cases of pterygium. "MMC has been repeatedly discussed in the scientific literature as causing blindness and I have personally seen at least six eyes lost after MMC for pterygium," Dr. Hirst wrote. Instead, Dr. Hirst pioneered the PER- FECT technique, which involves leaving the exposed sclera bare and requires no adjuvants. Dr. Lee, who co-authored a study on MMC-associated stromalysis after pterygi- um surgery, 3 also uses a modified PERFECT technique described by Dr. Hirst and does not feel MMC is needed as recurrence following the technique is rare. "I personally do not use MMC for a primary or recurrent pterygia but would not fault a surgeon for considering its use in a recurrent pterygium with severe con- junctival fibrosis," he wrote. "Always take care to avoid applying it directly to bare sclera when used as it has been associated with necrotizing scleritis, scleral necrosis, scleral melts, and calci- fication of the sclera." superficial keratec- tomy is performed and the cornea ap- pears clear and the topography shows regular corneal astig- matism, I would be more inclined to use a toric IOL." "It is important to recognize that EBMD can both increase manifest astigmatism or also mask existing cylin- der," wrote Dr. Kim and Dr. Goerlitz-Jessen. "Also, EBMD often causes irregular patterns of astigmatism, which are poorly corrected with toric IOLs. If the corneal surface is not properly addressed prior to the use of a toric IOL, visual outcomes are unpredictable and patients are often unhappy. "If the ocular surface is optimized, a patient may become an excellent toric candi- date and end up doing exceptionally well," they continued. "However, it is also important to discuss the recurrence of EBMD with patients, which is seen in up to 13% of cases. 2 If EBMD recurs, the astigmatism correction from the toric IOL can be adversely affected, potentially requiring additional treatment to once again optimize the cornea and reap the benefits of their toric lens." Superficial lamellar vs. PTK All the doctors agree that in most cases a super- ficial lamellar keratectomy is enough to manage lumps and bumps, reserving PTK for deeper, typically recurrent or refractory lesions that penetrate into the stroma. They caution that PTK, which may cut into the Bowman's layer or even the stroma, has a greater risk of creating haze and/or scarring, although the use of mito- mycin C (MMC) mitigates the risk. Adjuncts? MMC is a useful adjunct to prevent recurrence in the case of Salzmann's nodules. It is, how- continued from page 37 References 1. Goerlitz-Jessen MF, et al. Impact of epithelial basement membrane dystrophy and Salzmann nodular degeneration on biometry measurements. J Cataract Refract Surg. 2019 Aug;45(8):1119–1123. 2. Germundsson J, et al. Clinical outcome and recurrence of epithelial basement membrane dystrophy after phototherapeutic keratectomy: A cross-sec- tional study. Ophthalmol. 2011;118:515–22. 3. Lindquist TP, et al. Mitomycin C-associated scleral stromalysis after pterygium surgery. Cornea. 2015 Apr;34(4):398–401. Relevant financial interests Goerlitz-Jessen: None Hirst: None Kim: None Lee: None Mian: None Rapuano: None "If the ocular surface is optimized, a patient may become an excellent toric candidate..." —Terry Kim, MD, and Mark Goerlitz-Jessen, MD

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